Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide adequate grooming care for a resident, as evidenced by the presence of a dreadlock in the resident's hair. The resident expressed that grooming services should be part of the care provided, indicating a lack of attention to personal hygiene needs. Additionally, the facility did not implement a bowel management program for another resident, who was at risk for constipation due to decreased mobility and medication side effects. Despite having physician orders for routine and as-needed medications, there was no documentation of bowel movements or administration of as-needed medications over several days. Another deficiency involved the failure to notify a physician about a resident's condition as per the order. The Director of Nursing acknowledged the absence of documentation regarding physician notification. Furthermore, the facility did not ensure proper supervision and education following an incident where a resident was left alone in her room, leading to a fall. The care plan lacked interventions to prevent such incidents, and education was only provided to the staff member directly involved, rather than all staff. The facility also failed to follow physician orders for feeding a resident who was dependent on tube feedings for nutrition and hydration. The resident had severe weight loss and was receiving a significant portion of her daily caloric and fluid intake through tube feedings. The care plan for nutrition was not adequately addressing the resident's needs, contributing to the deficiency in care provided.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #72 was assessed by licensed nurse, provided hygiene assistance with nail care, grooming, shaving and shower; no other concerns identified. To ensure parameters in place per physician orders and follow up scheduled as indicated. Any issues identified were corrected. On 4.14.25 a quality review was completed by Director of Nursing/designee on current residents who sustained a within the last 30 days to ensure follow up documentation in place, care plan updated, and staff education completed. Any concerns identified were corrected. On 4.11.25 a quality review was completed by Director of Nursing/designee on current residents receiving nutrition to ensure appropriate formula in place and rate reflective of physician orders. Any issues identified were corrected. On 4.11.25 a quality review was completed by Director of Nursing/designee on current residents with sites in place to ensure in place, changed timely and physician orders for monitoring being followed. Any issues identified were corrected. On 4.14.25 a quality review was completed by Director of Nursing/designee on current residents with in place to ensure physician orders being followed and is administered properly. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur? On 4.22.25 Director of Nursing completed education with current staff on the components of N201 right to adequate and appropriate health care with emphasis on providing hygiene/grooming/nail care/showers per resident preference by the Assistant Director of Nursing/designee. Newly hired nursing staff will be educated on the components of N201 right to adequate and appropriate health care with emphasis on providing hygiene/grooming/nail care/showers per resident preference by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. On 4.22.25 Director of Nursing completed education with current staff on the components of N201 right to adequate and appropriate health care with an emphasis on monitoring, parameters, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated by the Director of Nursing/Designee. Newly hired licensed nursing staff will be educated on the components of N201 right to adequate and appropriate health care with an emphasis on parameters, monitoring, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated by the Assistant Director of Nursing/designee.